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Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

Treatment Compliance in Patients With Co-Occurring Mental Illness and Substance Abuse

Compliance is a crucial determinant of the treatment outcome of any medical
condition. Poor treatment compliance may affect the therapeutic alliance;
create skepticism in both therapist and patient; create resistance; worsen the
disease or the prognosis; and increase health care costs (Osterberg
and Blaschke, 2005). Unfortunately, poor treatment
compliance is often associated with blame, and noncompliant patients are
sometimes punished with involuntary administrative discharge from treatment.

There are multiple indicators of treatment compliance that can be measured
using direct or indirect methods. Among the direct methods, investigators and
clinicians have used actual attendance to therapy sessions, direct observation
or video-recording of sessions, measurement of medication blood levels,
surrogate markers of medication, or expected changes in laboratory values. The
indirect methods include self-reported compliance, pill counts, evidence or
absence of expected side effects, and electronic monitoring devices.
Unfortunately, the direct methods are expensive, and the indirect ones can be
subject to biases.

In psychiatry, treatment compliance may be affected by factors associated
with the therapist's characteristics, the service, the nature of the treatment
and the patient's idiosyncrasies. The therapist may not adhere to the
recommended treatment guidelines or the therapy manual. The services may affect
compliance if they are hard to access or have long wait times, long lapses
between appointments or complex administrative procedures. Treatments that
involve complex procedures, are hard to follow, have unpleasant side effects,
take a while to produce the desired effect, and are either unavailable or
difficult to access may increase the chances of poor compliance. The
characteristics of the patient, such as the presence of comorbid
mental illness and substance use disorders (SUDs),
can greatly affect treatment compliance.


The interest in psychiatric comorbidity increased
with the publication of results from the Epidemiologic Catchment
Area Study (Regier et al., 1990) and the National Comorbidity Study (Kessler et al., 1994). More recently,
Kessler et al. (2005) showed that the relative magnitude of associations of
having at least one substance use disorder in the past 12 months was
significant for all but two mental conditions. The prevalence of mental health
service use in the past year was only 41.1% and 38.1% for individuals who had
any mental disorder or any substance use disorder in that time period,
respectively (Wang et al., 2005).

Unfortunately, little is known about the proportion of individuals in the
general population who use mental health services and actually adhere to their
treatment plan. A survey of psychiatrists showed that 40% of their patients
with SUDs had treatment compliance problems (Herbeck et al., 2005). Both clinical and nonclinical factors appeared to be associated with
treatment compliance problems. Among the clinical factors, patients with low
treatment compliance were more likely to have personality disorders, lower
global assessment of functioning scores and medication side effects than those
without treatment compliance problems (Herbeck et
al., 2005).

It has been reported that the rates of completion of clinical trials for
chronic medical conditions are only between 43% and 78% (Osterberg
and Blaschke, 2005). It is likely that for those with
psychiatric disorders, particularly with comorbid SUDs, this percentage may be even lower. According to a
meta-analysis of medication compliance, the mean compliance rate for patients
with physical disorders was 76%, whereas the ratio for patients taking
antidepressants was 65% and 58% for antipsychotics
(Cramer and Rosenheck, 1998). It has been estimated
that medication noncompliance accounts for about 40% of re-hospitalizations of
patients with schizophrenia (Weiden and Olfson, 1995).

The concurrence of mental illness and SUD seems to have a negative
synergistic effect. It has been suggested that comorbid
psychiatric disorders can further increase the risk of relapse and can have
important implications for predicting treatment outcomes (Compton et al.,
2003). The rates of treatment compliance among patients with SUD vary greatly,
depending on the type of SUD and treatment, severity of the disorder, degree of
psychosocial support, and the presence and severity of psychiatric comorbidity. Patients with only alcohol use disorders have
significantly higher treatment retention rates (42%) than those with drug use
disorders (20%) or combined alcohol and drug use disorders (26%) (McCaul et al., 2001).
Furthermore, clinical trials of treatments for cocaine and other stimulant use
disorders have difficulty retaining participants. In contrast, clinical trials
of opioid agonist medications have better compliance
rates (De Castro and Sabate, 2003).


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